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The Transition of Care Service Coordinator is responsible for care coordination of our members who are experiencing a significant change in health status which has resulted in an inpatient admission. The Transition of Care (TOC) Service Coordinator ensures the member experiences a seamless transition to their next care setting.Position Responsibilities

• Responsible for telephonic and/or face to face assessing, planning, implementing, and coordinating all care management activities with members to evaluate the medical and behavioral health needs to facilitate the member's overall wellness.
• Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration.
• Using clinical tools and information/data review, conducts comprehensive assessments of member's needs and recommends an approach to case resolution by meeting needs in alignment with their benefit plan and available internal and external programs and services.
• Applies clinical judgement to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Complete assessments taking into account information from various sources to address conditions including co-morbid and multiple diagnosis that impact functionality and include the member's restrictions/limitations.
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Use advanced clinical skills to perform crisis intervention with members experiencing a behavioral or medical crisis and refer them to the appropriate clinical providers for assessment and treatment as clinically indicated.
• Attends and participates in case rounds, including utilization management rounds for behavioral health and physical health to obtain multidisciplinary view to achieve optimal outcomes.
• Collaborates with the member, and inpatient facilities to coordinate discharge needs including ensuring post discharge needs are met.
• Utilizes influencing/motivational interviewing skills to ensure maximum member engagement and discern their health status and health needs based on key questions and conversation.
• Provides coaching, information, and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Helps member actively and knowledgably participate with their provider in healthcare decision-making.
• In collaboration with the member and their care team develops and monitors established plans of care to meet the member's goals.
• Utilizes care management processes in compliance with regulatory and company policies and procedures.
• Follows members identified as inpatient in hospitals (whether planned or unplanned admission) and throughout subsequent care continuum.
• Facilitates clinical hand offs during transitions of care.
• Reports to: Manager, Clinical Health Services

• Active current unrestricted RN licensure in the state of Texas OR Licensed Social Worker in the state of Texas
• Must reside in Bexar County or adjacent county
• 3+ years clinical practice experience, e.g. hospital setting
• 3+ years of discharge planning experience
• 2+ years' experience managing complex medical
• 2+ years behavioral health conditions
• Willing and able to travel 50% of their time to meet members face to face in the Bexar County area. Reliable transportation required; Mileage is reimbursed per our company expense reimbursement policy
• 2+ years' experience using personal computer, keyboard navigation, navigating multiple systems and applications; and using MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)

• Behavioral Health Experience
• Case management in an integrated model
• Experience providing care to the Medicaid population
• Bilingual in Spanish

• RN license: Minimum of an Associate's in Nursing required
• BH License: Minimum of a Master's degree in social work or related field required